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HomeMy WebLinkAbout434510 T-MOBILE USA - INSURANCE CERTIFICATE (2)AC"Ro° CERTIFICATE OF LIABILITY INSURANCE 5/l/2020 DATE(MM/DD/YYYY) 4/23/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lockton Companies Three City Place Drive, Suite 900 St. Louis MO 63141-7081 (314) 432-0500 CONT CT NAME: A/C, PHONE Ext : AIC No E-MAIL ADDRESS: INSURER AFFORDING COVERAGE NAIC # INSURER A: XL Insurance America, Inc. 24554 INSURED T-Mobile US, Inc. 1358772 Its Subsidiaries and Affiliates 12920 SE 38th Street Bellevue WA 98006 INSURER B: Greenwich Insurance Com anv 22322 INSURER C: National Union Fire Ins Co Pitts. PA 19445 INSURER D : INSURER E : INSURER F : COVERAGES TMOBI CERTIFICATE NUMBER: 12219014 REVISION Nl1MRFR- XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP (MMIDDfYYYY1 LIMITS B X COMMERCIAL GENERAL LIABILITY Y Y RGD5000259-08 5/1/2019 5/1/2020 EACH OCCURRENCE 1,000,000 CLAIMS -MADE � OCCUR PREMISES (Ea RENTED ) $ 1,000,000 MED EXP (Any oneperson) 5,000 PERSONAL & ADV INJURY $ 1000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY❑ JECOT- FLOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y RAD5000257-08 5/ 1 /2019 5/1/2020 COaBINEDtSINGLE LIMIT $ 2,000,000 X BODILY INJURY (Per person) $ XXXXXXX ANY AUTO AAUTOS ONLY SCHEDULED BODILY INJURY (Per accident $ XXXXXXX AUTOS ONLY NON-OWNED ONLDY PROPERTY c ,J. DAMAGE $ XXXXXXX $XXXXXXX C X UMBRELLA LIAB X OCCUR Y N 28295139 5/1/2019 5/1/2020 EACH OCCURRENCE $ 5000000 C EXCESS LIAB CLAIMS -MADE SIR applies per policy &conditions AGGREGATE $ 5,000,000 DED X RETENTION $25,000 $ XXXXXXX A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N RWD5000301-07 AOS 5/1/2019 5/1/2020 PER OTH- X STATUTE ER A ANY YIN ECUTIVE N / A RWR5000302-07 WI 5/1/2019 5/l/2020 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder and other entities defined by written contract, statute, permit application or written agreement are additional insureds on a primary and non-contributory basis under general liability and are additional insured under automobile liabilit as required by written contract. Waiver of Subrogation * applies under generaf-liability and automobile liability as required by written contract. See Attached Endorsements" DN03245A - 137 N Bryan Ave, Fort Collins, CO ­♦r ..--.a- I IVI\ J60l LLaG111110111_1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE , NOTICE RECEIVED ACCORDANCE WITH THE POLICOY PROVISIONSILL BE DELIVERED IN 12218014 MAY 0 3 2019 AUTHORIZED REPRESENTATIVE City of Fort Collins City Manager PO Box 580 300 Laporte Avenue Fort Collins CO 80522-0580 City Manager's officF 1W ACORD 25 (2016/03) ©1 The ACORD name and logo are registered marks of ACORD N. All riahts reserved